Nutrition and fluid balance must be taken seriously

BMJ 2013; 346 doi: (Published 8 February 2013)
Cite this as: BMJ 2013;346:f801

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This review brings together much well used information on the severity of the problem of Nutrition and Fluid balance. However as similar initiatives in the past have failed it will not lead to the transformation required.

There are several major issues.

Firstly whilst commissioning may require specialist assessment of risk it remains poor at commissioning capacity to manage the problem. Consider the swallowing assessment of a person with borderline capability, this may result in a regime of careful positioning, thickened fluids, modified diets and a slow assisted feeding. To provide a dignified and adequate meal may take in excess of an hour. Whether the patient is in an acute hospital bed or care home potentially the feeding of one individual may consume the equivalent of half a nurse or trained carer each day. It only requires 4 or 5 people with similar needs to be cared for by the same team for the who may have 25 other patients with competing and time consuming needs as well as the routine work such as medicines management. This is the nub of the problem in hospitals and in care.

The result is that for many people supplemental liquid feeds are prescribed and on occasion PEG tubes used, these approaches are costly and having observed a threefold variation in the prescribing of supplemental feeds to care home residents between different PCTs there is clearly unwarranted variation. I would propose that as well as assessing swallowing capability dieticians should be assessing the likely feeding support an individual and a ward or care home collectively requires so that commissioners can ensure adequate staffing. The use of expensive supplemental feeds should be subject to continual surveillance, it is likely much saving can be made and that may help fund increased feeding care support.

Secondly, a rather uncritical implicit sense permeates the issues of malnutrition namely that its prevention and active treatment improve all patients well being. I question this, people with advanced disease often have related cachexia and may be inappropriately cajoled into eating in a way they may find discomforting and which will have little or no bearing on their well being. Few if any patients I have asked relish the various liquid supplementary feeds.

The majority of cases of malnutrition and poor fluid balance are a result not of Gastrointestinal or Renal disease but frailty, neurological disease and long term conditions including cancer. Any assessment should not just be of the risk of malnutrition but its context and the potential patient benefit for intervention as in any treatment.

Competing interests: None declared

Clive E Bowman, Geratologist

Visiting Research Fellow, University of Hertfordshire, Bonvilston, Vale of Glamorgan

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The Need for Nutrition Education Programme (NNEdPro:, comprising doctors, dietitians and other health care professionals, is very pleased to see this article which reiterates the issues that we have also been working in response to for the past five years. We strongly agree that there needs to be a greater emphasis on nutrition and hydration education amongst all healthcare professionals, particularly tomorrow’s doctors. As a multiprofessional group, we have approached this topic by designing, piloting and implementing innovative nutrition teaching modules for medical students (NNEdPro Phase 1)[1-3] and junior doctors (NNEdPro Phase 2)[4] drawn from across the UK. In Phase 2, Nutrition Education and Leadership for Improved Clinical Outcomes (NELICO), the NNEdPro group trained junior doctors from across three NHS regions on the importance of nutrition and hydration.

Although this article highlights the perceived lack of interest among clinicians in this topic, we found that by raising the awareness of medical students and junior doctors, we could motivate them to take action. As part of NELICO, we also provided training on change management and leadership, giving participants an opportunity to apply those skills to improve nutritional care in the hospital setting. They were supported to work in teams to run hospital nutrition awareness weeks. This allowed the junior doctors to apply their newfound knowledge and skills by working as part of a multi-disciplinary team and to raise nutrition and hydration awareness amongst their peers and other hospital staff. The teams worked closely with the dietitians in the hospital and other staff involved in hospital nutrition.

We are pleased to see the development of nutrition curriculum recommendations by the Medical Royal Colleges, to fill a critical gap. Evidence from the work of the NNEdPro group to date, would suggest that such curriculum recommendations can be implemented effectively in medical schools as well as NHS settings. It is therefore timely for educational policymakers to bring these two ends together to improve nutritional care in our hospitals as well as aspects of community care impacted by nutrition and hydration.


[1] Ray S, Laur C, Rajput Ray M, Gandy J, Schofield S. Planning Nutrition Education Interventions for the Medical Workforce: ‘Nutrition Education Workshop for Tayside Doctors’ (NEWTayDoc) - A pilot project to inform development of the Need for Nutrition Education Programme (NNEdPro). MedEdWorld. 2012.

[2] Ray S, Udumyan R, Rajput-Ray M, Thompson B, Lodge K-M, Douglas P, et al. Evaluation of a novel nutrition education intervention for medical students from across England. BMJ Open. 2012 January 1, 2012;2(1).

[3] Laur C, Thompson B, Ray S. Short but effective educational interventions in medicine and healthcare – lessons learnt from the ‘Need for Nutrition Education Programme’. MedEdWorld. 2012.

[4] Ray S, Laur C, et al. Nutrition Education and Leadership for Improved Clinical Outcomes: Training and supporting junior doctors to run a ‘Nutrition Awareness Weeks’ across three English hospitals. In Press. 2013.

Competing interests: None declared

Sumantra Ray, NNEdPro Honorary Chairman

Celia Laur, Minha Rajput-Ray, Pauline Douglas (On behalf of the NNEdPro Group)

The Need for Nutrition Education Programme (The NNEdPro Group is hosted by the BDA), c/o MRC Human Nutriton Research, The Elsie Widdowson Laboratory, Cambridge CB1 9NL

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I was really pleased to read this well written, comprehensive article on nutrition by Dry Leach and colleagues. It does cover lot of detailed information and more over it is very much topical in the present NHS. Authors have made a very good case for all of the team managing a patient under their care to be considering the issue of patient’s nutrition.

This article is so topical as nourishment / feeding issues are in public domain either highlighted in the national – local news / stressed in published reports / covered in patient forum.

It is well and good for various authorities to come up with various recommendations, but when there is budgetary restrictions, which are only getting tighter and tighter, its unfortunate that some aspects of patients care are not covered are they should be. With various staffing crisis and reducing of head count locally and nationally (weather it is due to gross budget cut nationally OR local trust trying to adjust its book), remaining staff are busy trying to cater to medical needs and to complete their important report writing. It is not surprising that they are struggling to feed individual patients, as they can’t do multiple jobs at the same time.

Authors really make a very good medical and financial case for why we shouldn’t ignore nutrition of patients. In the present environment as everything is weighed up financially, hospital trusts should really start considering some rational measures, either to increase nursing staff headcount, having allied healthcare staff (HCA’s) on the ward who should take care of feeding of patients. Which would not just help in making indirect savings but also helps to improve better patient satisfaction and positive hospital experience. Also in the primary care restrictions on prescribing of nutritious feeds – drinks should be lifted and access to a community dieticians are made quicker & easier.

This article should also be read closely by the nascent CCGs as on a longer run giving due consideration to good nourishing diet will only help in smaller bill per admitted patients (as duration stay is lesser, sick patient recoup sooner when well nourished)

The national media (newspapers / TV) should also start considering to air / cover free adverts on the topic of nourishment as a part of their social responsibility. It was good on the part of government to popularize five a day concept regarding fruits and vegetables. Government should run another wave of national coverage on the topic of nutrition. Other measures which government has at its disposal are making changing to the tax on healthy food.

Competing interests: None declared

Siddappa Gada, GP

Holbrook and Shotley surgeries, Shotley surgery

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Lack of hydration seems to be one of the most serious problems in hospitals that have failed in their duty of care, mainly because glasses of water are placed out of reach. A simple solution is to give patients a 'sports' bottle of water that they can drink from at any time.

My husband had a stroke five years ago, which deprived him of sight, and mobility on his right (dominant) side. The medication he was on also made him thirsty. When he got home we soon found an easy solution to the problem: the sports bottle, which he could use himself at any time. It doesn't leak when kept within easy reach in the bed. Why don't hospitals follow suit?

As for nutrition, I found that when he was in hospital I was welcomed at mealtimes (even when these were not strictly during visiting hours) so that I could help with feeding. Otherwise he tended to ask for sandwiches only, since these were easy to eat with his 'good' left hand. At least one Scottish hospital now welcomes volunteers to help with feeding patients who can't manage to feed themselves. This could surely be one solution to the problem. Another helpful gadget we only found out about when we got home is the 'plate guard', a simple plastic device that prevents food from sliding off the plate when the patient can only use one hand. All these low-tech suggestions are practically cost-free.

Competing interests: None declared

Heather M. Goodare, retired

lay referee, Cochrane Collaborationtion, 3 Glengyle Terrace, Edinburgh EH3 9LLH3 9LL

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Dear Sir,
we read with interest the paper by Leach and colleagues which was recently published in the Analysis section of the British Medical Journal (1).

The article neatly highlights that, although delivery of adequate fluid and nutrition should be a clear responsibility of all healthcare professionals, access to appropriate nutrition and hydration is still largely unmet in all types of healthcare facility in the UK. This is amazing, not only under the ethical perspective, but also when one considers the dramatic impact that malnutrition and dehydration have on outcome and healthcare costs (1).

Interestingly, the recent perspective by Krumholz in the New England Journal of Medicine, focusing on the post-hospital syndrome (2), pointed to the same direction: most of the hospital-discharged patients have heightened risks of several complications, in turn leading to hospital-readmissions, many of which have little in common with the initial diagnosis. In particular, a crucial role in determining impairment of wound healing, increased infection rates, decreased respiratory, cardiac and cognitive function seems to be played by malnutrition (2-4). Thus, malnutrition represents a common, albeit insidious comorbidity which is likely to determine the largest increase of hospitalization costs (5). Lim at al recently showed that average cost of hospitalization is 24% higher for malnourished patients and that the risk of readmissions within 15 days is increased by 60% for malnourished patients when compared to well-nourished patients (4).

Malnutrition recognizes a complex and multifactorial pathophysiology, in which insufficient food intake, altered metabolism and, in some cases, increased basal energy expenditure all play a relevant role. Anorexia, defined as the reduced desire to eat, is highly prevalent in acute and chronic diseases, causing reduced energy and protein-intake, thus significantly contributing to the clinical picture of malnutrition (6). A recent analysis of the nutritionDay® (an international and annual survey on hospital malnutrition’s prevalence and clinical impact) database, has demonstrated that anorexia is a risk factor for mortality in hospitalized patients (7). Moreover, anorexia and malnutrition are independently associated with in-hospital mortality and are strongly related to readmission rates within 90-days of discharge (8).

Quite surprisingly, as both Dr Leach and Dr Krumholz correctly point out in their articles, nutritional issues during hospital stay receive very limited attention. The question then arises: why is such a highly prevalent comorbidity disregarded and neglected in clinical practice, despite its detrimental effects on outcomes and healthcare costs? One possible answer is that malnutrition, unlike hypertension, diabetes, dyslipidemia, etc, is not yet recognized as a clinical risk factor, likely as a consequence of the limited and inconsistent teaching of nutritional matters in medical schools worldwide. Another hypothesis is that malnutrition, given the pathophysiological complexity, the phenotypical variability and the lack of simple operational diagnostic criteria, is often not recognized at all both in hospitals and in the community.

Promoting good nutrition and hydration and addressing nutritional deficiencies are among the strategies proposed to mitigate post-hospital syndrome and its accompanying risks (1,2). This represents a challenge for health professionals and healthcare systems which will be won if awareness of malnutrition and its early recognition and treatment will become an integral part of good clinical practice.

Unmasking the hidden killer represented by malnutrition will translate not only in a reduction of healthcare costs, but, above all, in an improvement of patients’ vulnerability and quality of life.

1. Leach RM, Brotherton A, Stroud M, Thompson R. Nutrition and fluid balance must be taken seriously. BMJ. 2013;346:f801. doi: 10.1136/bmj.f801.
2. Krumholz HM. Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk, N Engl J Med. 2013 Jan 10;368(2):100-2. doi: 10.1056/NEJMp1212324.
3. Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 2012;31:345e50.
4. Spaccavento S, Del Prete M, Craca A, Fiore P. Influence of nutritional status on cognitive, functional and neuropsychiatric deficits in Alzheimer's disease. Arch Gerontol Geriatr. 2009;48(3):356-60.
5. Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS. Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am 2012;94:9e17.
6. Molfino A, Laviano A, Rossi Fanelli F. Contribution of anorexia to tissue wasting in cachexia.
Curr Opin Support Palliat Care. 2010;4:249-53.
7. Hiesmayr M, Schindler K, Pernicka E, Schuh C, Schoeniger-Hekele A, Bauer P, et al, NutritionDay Audit Team. Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006. Clin Nutr 2009;28:484e91.
8. Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, Isenring E. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from the Nutrition Care Day Survey 2010. Clin Nutr. 2012 Dec 5. pii: S0261-5614(12)00269-5. doi: 10.1016/j.clnu.2012.11.021

Competing interests: None declared

Maurizio Muscaritoli, Associate Professor of Internal Medicine

Alessio Molfino

Department of Clinical Medicine Sapienza University of Rome, Viale dell'Università, 37 - 00185 Rome, Italy

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